Wiki Coding w/o a pathology

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KMayercsik

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Patient referred to our oncologist with a solitary pulmonary nodule, no pathology. The physician has entered a cancer diagnosis into the patient's EMR. She states that this is a clinical diagnosis based on her findings and patient history.
I have advised her against this in the event that medical records are requested to support medical necessity for the procedures she plans on providing. Her HPI is quite clear on why she feels confident in assigning this diagnosis.
Any thoughts on this, can I submit a cancer diagnosis with no pathological evidence?
 
I wouldn't without proof it is cancer. What if the patient was you. Someone sent to your insurance you had cancer without pathology, and after the testing it later came back as benign. You might not be able to get a life insurance policy, etc. I would put the nodule and then maybe neoplasm of uncertain behavior. What does everyone else think?
 
You cannot cod a neoplasm with out a path report. This includes neoplasm of uncertain behavior. You will code what you know which in this case is the nodule.
 
If the physician has made the cancer diagnosis, then that's what should be coded. It's not a coder's place or scope of practice to tell a physician what information they require to make a diagnosis. It's one thing if a physician doesn't understand coding guidelines and selects an incorrect code, but quite another if you've queried them and they've confirmed for you that this is their diagnosis for the patient.
 
It does not sound like a cancer diagnosis has been made based on what the post says. It sounds like a diagnosis of a lung nodule yet the provider assigns a cancer code. This is not the same as a diagnosis of cancer. The provider would need to render a neoplasm diagnosis within the context of the exam note. A diagnosis code is not a rendered diagnosis.
 
Coding w/o a pathology report

The biopsied tissue is a neoplasm, but has been supplied to a pathologist for examination and determination of a Dx. Without a pathology report, all the requesting physician can code is neoplasm of unspecified behavior, NOT uncertain behavior. If the neoplasm were given a histo-morphological type of uncertain behavior, then the requesting physician would be on safe ground to code the uncertain behavior.

See http://www.psnextra.org/Columns/CPT-Corner-June-2011.html, but even more definitive, check the Guidelines. Checkout D48 for uncertain behavior, as opposed to D49 for unspecified behavior between the time the Bx was taken and when the pathology report arrives.
 
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